By the time we woke up, TB had gotten ahead

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J. Peter Cegielski, Team Leader for Drug-Resistant Tuberculosis at the CDC, International Research and Programs Branch, Division of Tuberculosis Elimination (DTBE), likened the tuberculosis epidemic to the fable of the tortoise and the hare. “By the 1980s we thought that TB had been conquered. We fell asleep of the wheel….. While we stopped to take a nap, the TB tortoise bypassed us. By the time we woke up, TB had gotten ahead.”

He noted that it is critically important that we begin testing new drugs for TB in combination.  Introducing one new drug at a time makes that agent extremely vulnerable to resistance.  He praised the new  “critical path initiative” that has brought government agencies, including the FDA together to do exactly that.

William Burman , Professor of Medicine at University of Colorado School of Medicine, Division of Infectious Diseases; Medical Director of the Infectious Diseases Clinic of Denver Public Health, echoed that same sentiment. And, he captured the reason why we (as Americans) should care.   “We need to avoid the complacency of TB in the United States. Because TB anywhere, is TB everywhere.” Indeed, TB travels on the wings of a cough and knows no borders.

One statistic grabbed the audience’s attention: One-third of patients in the U.S. with extensively drug-resistant tuberculosis die.

Globally, 20% of TB patients have drug-resistant TB, and 5% to 6% have MDR TB. The three problem regions cited  by Dr. Burman were the countries of the former Soviet Union (recently released data show some areas are reporting a rate of MDR TB as high as 20% in newly diagnosed case), parts of South America, and Sub-Saharan Africa. In Sub-Saharan Africa, in particular, the broad-based HIV epidemic , when combined with the threat of TB, has caused a “public-health catastrophe.” More than half of these patients die.

Both speakers called for a dramatic increase in resources and attention to TB diagnosis, treatment, and prevention. For example, we learned in the 1950s that TB drugs need to be given in combination, but industry and researchers continue to put them out one at a time.

AIDS activist Mark Harrington called the inability to diagnose TB in the vast majority of people the “Achille’s heel” that needs to be addressed. Sputum microscopy is an incredibly inefficient way to diagnose TB since it only identified 40 percent of the cases. But Harrington, executive director of the Treatment Action Group, noted that even this primitive diagnostic technique is elusive in many developing world settings. In Kenya, for example, only 18 percent of diagnostic sites have a functioning microscope.  Although some higher technology machines are in the pipeline, Harrington said the costs are prohibitive.  One machine costs $27,000, with a cartridge costing $700.

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